Classic Case: Granuloma from Histoplasmosis

This is a classic case of a granuloma due to prior histoplasmosis. In the vast majority of histo infections, patients are either asymptomatic or have minimal symptoms. It is only later that a granuloma is found incidentally. When the granuloma is calcified, it is not a diagnostic challenge. When the granuloma is not calcified, the nodule can be mistaken for other lesions including cancer. That is where a radiologist can play a big role in the diagnosis and management--by steering the patient towards follow up imaging rather than a more invasive test.
Textbooks I like for chest radiology-
Med students and all residents: Felson’s Principles of Chest Roentgenology
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Radiology residents: Thoracic Imaging: Pulmonary and Cardiovascular Radiology
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Thoracic radiology fellows: Muller’s Imaging of the Chest: Expert Radiology Series
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[@manylander]

Extrememly clear explanation, perfect pace and a smooth delivery. Thank you Dr. Agrawal.

[@anitcolor]

i cant believe its not cancer, thank you for this case (from 3 young radiologists that just got smarter)

[@kristineanderson4983]

Wow, finally a real description of what my lungs look like. I contracted histo in 1982 at an outdoor wedding in a rural, woodsy area in Minnesota. I was very sick, and hospitalized along with two others. A total of 132 people got it, but most cases were very mild. One person almost died, however. The spores from the bat poop came down from the roof area of the church, which was negligent in keeping it clean. We won a law suit, but not enough money to spit at. I lost 25 pounds in two weeks and was small to begin with. I was so sick and in so much pain with a fever that lasted for six months, it was a horrible time for a 29-year-old "healthy" girl. My chest X-Ray looks like the perfect display of fireworks! I have nodules that are being watched, but my docs know nothing about histo and never bring it up; they're watching for cancer. I live in a rural area now; healthcare is a whole new ballgame! Thanks for this video.

[@ThoracicRadiology]

wow, I wonder how the couple must have felt knowing that their closest family and friends all got sick. glad you got over the infection, but yeah the nodules will probably stay there forever, and they are probably calcified by now.

[@kristineanderson4983]

@@ThoracicRadiology Yes, it was quite the surprise outcome of a beautiful wedding. The nodules have been calcified for many years, and I don't worry about Histo. However, I never felt the same after that, and I've always wondered why I became so unhealthy -- RA, Raynaud's, now Sjogren's, Fibromyalgia, ME/CFS, more. I live in very serious chronic pain and now in an electric wheelchair. But! I'm still above ground and listening to that great 70s music! Take care and thanks for responding.

[@hasanulusoy9953]

Thank you for your excellent presentation 🙏

[@Greanestbean]

Thank you.

[@omarsalih142]

Informative lecture and very beautiful presentation… please keep going 👍👍

[@domenicogiannattasio9037]

thank you for sharing it but when you see a nodule in the lung and, for example, patient is a smoker, it is very difficult dont make contrast because the border between benign and malignant is very subtle also without spiculated apparent border.

[@ThoracicRadiology]

Yeah, context is important. If you don't live in an endemic area and the patient is a smoker, I would be suspicious for cancer. What I'm saying is that you shouldn't rush to biopsy if you see this pattern. You can do short term follow up.

[@domenicogiannattasio9037]

Really the contest Is important,it is true! In Southern Italy,where i live, is absolutely rare,perhaps some cases in Northern. Thanks you once again

[@shansra11]

Could you make a video on tips to distinguish atelectasis from consolidation? And acute from chronic PEs?

[@SaharAljurany-cw1lz]

Thank you very much

[@Christynmaine]

Really useful. Thank you. My granulomas are encapsulated yet lit up under a PET scan. No symptoms at all. I won’t be seeing a pulmonologist for a month. Looks like I may need a biopsy ☹️

[@ThoracicRadiology]

Hm, yeah if they have been stable for a long time (over 2 years), that to me is a pretty reassuring sign. You may need a biopsy but more likely just follow up scans.

[@Christynmaine]

@@ThoracicRadiology Thank you for responding. Hope I’ll just need follow up scans. 🤞

[@studywithdoctor823]

Explanation is amazing.but kindly use a pointer which is easily visible

[@ThoracicRadiology]

sorry, will use bigger pointer for next time.

[@user-qw8no5bl5m]

Thank you, insightful video. My step-father has histo (Arkansas daily walker) and one new small lung nodule. How to get rid of it and/or prevent calcification?? Also, are you available for consult?

[@ThoracicRadiology]

thank you, no I don't do consults. but if your stepfather has a normal immune system, then the body will take care of it. you don't have to worry about it when it calcifies. it will stay in the body, but it doesn't cause harm.

[@Drjohnson166]

Are there specific characteristics on CXR that make you certain that it is a granuloma, other than it being calcified?

[@ThoracicRadiology]

CXR, if I have an old study from at least 6 months ago and it is stable, that is one good characteristic. If I don't have an old study, and it is not calcified, I'm usually recommending a CT.

[@toradall8143]

Our house was next to chickens and covered head to toe in mold. I had gotten a CT due to kidney pain and they said my spleen had calcifications. I developed low bp, tinnitus, brain fog, joint pain, extreme fatigue, and chest pain and they found calcified chest lymph nodes and a small one in my lung. No real cough. My wbc have always been very low a 2-3, and my lymphocytes are always higher than my neutrophils. I never got any antifungals for my encounter with the chicken poop mold. My bloodwork for basic stuff comes back normal. My question is does histoplasmosis stay in the body quietly or are my organs and lymphs just permanently calcified now due to encountering it and its gone? Does calcification mean the fungus is dead? If it spread to spleen and lymphs isn't that disseminated?

[@ThoracicRadiology]

yeah the calcifications will just stay there, but vast majority of cases, they won't do anything. the fungus is said to be dormant meaning that it could potentially still cause illness, but only when your immune system is really weakened, like in people who are taken chemotherapy and who have AIDS. personally, i have not seen a case of histo coming back after being calcified though.

[@ZarinaKauser-no5vw]

Is their anyway to send you our report. We have a confusion if it is tb or metastasis

[@jay-resparagoza6796]

I have it too,calcified granuloma lower lobe my medical is for approval thats why i cant work abroad because of this..can you help me how to heal it? Thank you so much im from philippines I want to treat this ASAP thank you so much doc and godbless Any tips??

[@kirantilekar666]

A 2mm sized calcified granuloma is seen in the anterior segment of the right upper lobe What to do?

[@ThoracicRadiology]

calcified granulomas are benign lesions which do not have any malignant potential.

[@OlegTOA]

Thanks for the lecture. How to differentiate according to CT data with tuberculosis?

[@ThoracicRadiology]

Hi, I don't see that much TB where I live so my experience is limited. Are there others watching who have seen TB granulomas like this? @aiendail

[@OlegTOA]

@@ThoracicRadiology Yes, of course. This case fully corresponds to the CT manifestations characteristic of tuberculosis. According to computed tomography, it is impossible to distinguish them. In some cases, most likely, only surgery or a biopsy will help solve the problem. In addition, where you have shown layered calcification in the node, these changes are also characteristic of some types of tuberculosis (a separate type of organized tuberculosis is "tuberculoma"). How tuberculosis is diagnosed is known, these are skin tests, anamnesis, sputum analysis for mycobacterium DNA, sputum cultures, etc. For me, it was just a discovery that localized histoplasmosis looks identical. To sum up: are you sure that in your case there is definitely histoplasmosis, and not tuberculosis? Thanks for the discussion.

[@ThoracicRadiology]

@@OlegTOA thank you for that information. You're right, many of these are not biopsied. But where I live TB is pretty uncommon and histoplasmosis is very common, so it is just a numbers game.

[@sumathiaruleeswaran8]

perfect explanation sir. tnq so much. one doubt sir, follow up image at 7.55 Mts showed pleural tail sign,spiculations. if v couldn't follow this case,ven v happened to see fr d first time ,v might consider as suspicious nodule fr malignancy. since I don't know d size of the lesion. pls..

[@ThoracicRadiology]

yeah if it is spiculated, then I would be suspicious for malignancy.

[@Stella20450]

What was the outcome of your nodule?

[@jhane9036]

Good Day Doc.what the meaning of fibroreticular upper lobes densities.

[@ThoracicRadiology]

sounds like there is fibrosis in the upper lobes (like scarring in the lungs).

[@pontingeden8801]

I have a granuloma in my left upper lung

[@sheryarjaved323]

What are your symptoms?

[@bodhiagrawal8920]

Tito rushing found your channel!

[@ThoracicRadiology]

Thanks! Smash that like!

[@jennymaeesparagoza]

Hello sir i want to ask something even i have calcified granuloma can i apply job in canada? I really want to apply for my family..thank you so much and godbless you

[@ThoracicRadiology]

I really don't know. Is it from TB?

[@hickmathamieh934]

Can't another interpretation be lympanghitic spread? Carcinomatosis/sarcoidosis? Can ocassionally give the studded perilymphatic appearance... I would have a hard time not working this one up!

[@ThoracicRadiology]

Yeah if the big nodule is spiculated then I would work up too. But if it is smooth with surrounding nodules, I do follow up. I also live in Chicago where this is common, if you don't live in an endemic area, then you may be more cautious. Sarcoid is possible, but if it is only in 1 area, not as likely.

[@humnaimdad7761]

@@ThoracicRadiology if the size is around 4 cm solitary nodule which is calcified with a bronchovascular marking leading to it..with few non calcified lymphnodes

[@ThoracicRadiology]

@@humnaimdad7761 calcified nodule is usually benign, it sounds like a granuloma bit also depends on the pattern of calcification.

[@ajlavanetwork5755]

My sons CT is identical !! The R sided mass EXACT location too They took him into a GA BRONCHOSCOPE & biopsies of it only. DID NOT identify it as the above or abnormal Long story short COVER UP that you just can’t even MAKE up for a hollywood movie!! = HAS HAPPENED in my son’s case I am a ED Nurse learning constantly just how deep this actually goes… Deliberate calculated attempts to Bury this CASE & my concerns made to feel “in my head” hoping i’d be silenced by whatever false education or evidence they tried stating is normal, EXAMPLE; Can you please clarify the RIGHT (H) mass is located RUL??? Because that is the exact position my son has Further The opposite end IS RLL? “My sons lungs ARE EXACTLY the same!” They wrote these backwards in CT reporting as RUL partial mild spontaneous collapse normally occurrence associated to anaesthesia. INSTANT ESCALATION CALLED by myself (I didn’t know they deliberately wrote it back to wrote to try say ANAESTHETIC & FURTHER blame “aspiration” as the cause! Iv only now uncovered that too!!! He has SIGNET RINGs sign & guaranteed lung scarring ++ They put him on the cystic fibrosis abx & HTN nebs as a treatment for 6 months (lying its for a SEVERE TBM he hasn’t got!! CT did not detect or write narrowing anywhere? Location & landmarks i am looking at of when the BRONCHOSCOPY tube enters airway on screen if that is larynx ? As I thought it looks like a head right at back of that large circle > libs L & R circles? The tube starts from the big circle on screen anatomy? Subglottic? Region? Then is ir trachea pipe all the way down until just reaching the lungs? ** noting from the moment the tube enters the airway pipe on screen until about 4 cm before the tube enters the lungs = NI BLACK SPACE at all surrounding the tube The airway pipe is only OPEN because the tube is KEEPING IT OPEN! Or is that tube when it starts on screen until just before the lungs his SUPRAglottic / larynx region? He has been diagnosed with supraglottic stenosis / Collapse & development of SEVERE 38 AHI/ HR OSA 3 weeks post and ALLEGED TONSILECTOMY! (Uncovered his tonsils were not removed they were SHRINKED using MONOPLOR No TIP as per policies for thar device in records! FURTHER that is not a practice allowed on peadiatric airways AND NOT BY A REGISTRA who’s a trainee supposed to be supervising that DR. However intra op records evidence he was mot scrubbed into OT yet on site! Another detail is post the bronchoscopy TONSILLECTOMY •>>> LBO started 0930 hours > looking through travhea/bronchus 0950 hours significant RSI drugs commenced boluses then transfusions PAIN RELIEF where he had HIGH OBs all of a sudden & gets given adult doses of fentanyl, dex, Rsi Drugs , going onto a ventilator in OT surgery lasting 1 hour & 36 minutes. (Records lied written stating he left 35 mins post starting > yet drugs/ obs/ ventilator not able to breathe himself / addertete breathing = still in theatres! !! Aneastic & surgeons written note a lie!! Gets to RECOVERY 1106 distressed everyone trying to hold him & stop him pulling his airway device’s off & the Dr got us from recovery right at that exact same time so I didn’t click he was in OT 1.5 hours & instead thought he’d been in OT as normal & recovery that whole time since! Which i did Until iv seen PICU RN Documentation 1106 he arrived distressed!! Same time parents walked in Further wrote ; He can not maintain airways if he lays flat SIGNIFICANT HEAD BOBBING, WOB & INSPIRATORY STRIDOR!! If she holds him upright it improves yet still is there (written evidence airway now like a severe laryngomalacia!) He airway has never recovered & been what he was before he went under that ENTs miss management & further COVERED UP DELIBERATE attempts to bury this are CALCULATED. A call Dad received while he was in OT asking for permission to inject botox injection into his Larynx cleft (Dr deliberately called him & not me! Knowing i am ED RN id say no! As he had pneumonia as it was he was high risk for ICU post tonsillectomy No BOTOX INJECTION IN INTRAOP RECORDS Yet written as if GIVEN IN INTRAOP DOCUMENTATION!! On OT REPORT. SEEING YOUR CT videos & underneath myself this past 1.5 years all the knowledge on ENT / etc surgical procedures/management i didn’t know back then = This was not a mistake error! He has assessed the lungs found all the proof iv been going on about since his last surgery that he has significant EXCESSIVE SECRETIONS /> chest infection > into left for so long lung damage! I saw his FNE scope 4 months post that Surgery LARYNx NORMAL PERFECT V SHAPED VOCAL CORDS > LONG Only did notice “granulation bumps on his larynx A & E folds. Fast forward i am now significantly concerned he deliberately tried to cover up the big problem he refused to listen too!!! Dismissing me like parental anxiety!!! Yet his lungs ended up being exactly what i was raising concerns about OCCURRED! After seeing lungs with rigid & flexi scope > all those drugs he was not supposed to get are given & in progress He ends up with the a SUPRAGLOTTY plasty (A & E folds 3quarters to half of the length of his = CUT OFF instead of long V vocal cords & normal looking appearances His epiglottis is like a curly snake flopping over unable to activate a normal he once had. Further his A&E folds area is sucking flipping into & under epiglottis & epiglottis doesn’t move = video shows complete inspirationally obstruction!!! He has a pin whole to breathe through ABOUT THE SIZE of a divided into x4 pieces 5cm = it would be about that piece size soaked jn secretions!!! So he has gone then to his tonsils & burned his airway this is NOT ALLOWED PRACTICE > not on peads!! Policy for ENT us Tonsillectomy (removal!!) My son had a monopolar plate on positioned in his abdomen during the fake tonsillectomy where they were nor removed. He didn’t use diathermy tip = results into deep tissue scarring of surrounding tissue’s > which I suspected occurred straight away on day 4 post op as he had a coughing choke tonsil bleed where x2 BIG LARGE DEAD tonsil’s came up!! usually the NOT DONE PRACTICE IN THAT OT OR shrinking Iv learned it burnings for 18 months post as in development of scar tissue > I will be escalating this case to the health complaints commissioner > once i link EVERYTHING they have covered to the ends of earth UP!! They said he was Aspirating thats why his upper lungs so bad!! Put him on PPI & why he got that botox injection into a normal cleft! (Speechie didn’t think he was aspirating ever either!!) Turned out HE NEVER WAS!!! Now because of your videos it has made complete sense why they have deliberately lied about findings in diagnostic reports = able to ensure i get no records of diagnostics!! If i get records I’ll believe the finding expected I am proud of the facts I knew nothing of this magnitude was going on to bury his case & leave him to be enshrined with no legs to stand out for early interventions! !!! Instead choosing to put himself before his duty of care & a whole bunch of team buddy teams enabling him to succeed! I am concerned then because if my son has the above> WHICH ITS EXACTLY THE SAME!! Then took him for OT BRONCHOSCOPY With Resp Dr doing biopsy only & thereafter on CF abx treatment of Abx I am concerned if i need to be doing anything more? We only have one specialised children’s hospital in our state. It’s obvious to myself & ENT head department there i can’t trust drs there with my son> they are not documenting the correct findings and interpretations into the finding’s report. Instead modifierd records in CTAP with the old ENT swapping out with the medical physician in there & then swaps out with radiographer = I didn’t understand why he’d be in there & or how-come he is doing the surgery? narrowing yet it has to be as you can not see any blackness surrounding the bronchoscopes tube as its goes all the way down from subglottic region & post DC How could he do a CTAP without a radiographer!! Unless this hospital Drs have different training? His ENT dr advised no no they don’t have these qualifications & instead he was shocked that was on the records because he said he cant do it . I noted the female anaesthetic Dr was in the room near CT where I dropped him off & she has documented as being in that role Surgeon documented as being scrubbed in, medical procedualists = normally = the one who undertakes the surgery? Yet instead he has has written not one record on that CTAP > it cannot be a coincidence that that CTAP report also DOESN’T MATCH THE CT!! Cxray undertaken by ICU post CTAP (tuesday) then post on Saturday CXRAY taken stating new RLL collapse identified NOW DOING it too= evidenced some more this wasn’t anaesthesia related like I stated!!! It since since HIS LAST OT with him! A huge peadiatric A-Z documented my escalation concerns > documented how it started& every single POINTs occurrence & concerns up until here! Further i called out BS RADIOGRAPHer reports are wrong!!! He has had this since Nov!’!! Had i not watched all of your videos I never would of detected the COVER up on his CT!! Or the BS cover he has severe TBM YOU CANNOT GROW OUT OF IT!! He has a cobblestoned entire throat anatomy where tonsil shrinkage occurred . Iv never seen anything like it ESPECIALLY in a noy even 3 yr old! He has so much calcification on the other lung concerns going on that … I need to take his CT to be reviewed elsewhere & report them all from here ! Thankyou

[@judjudersawn2596]

Madam, your son is important and if he suffered from malpractice that is important to know. Would you consider trying to make your write up more succinct? I know it can be difficult when you are so caught up in the situation. But your write up as it is can be difficult for readers to follow.